Nersissian Health Management Group, DAB CR6558 (2024)

DECISION

Petitioner, Nersissian Health Management Group,1 challenges the determination of its effective date of Medicare enrollment and billing privileges as a biller to the Medicare program by Respondent, the Centers for Medicare & Medicaid Services (CMS), acting through its administrative contractor, Noridian Healthcare Solutions (Noridian). As explained herein, I affirm CMS’ effective date determination.

I. Background

On March 4, 2021, CMS received, via certified mail, an application from Petitioner to reassign Tigran Avoian’s (Dr. Avoian’s) Medicare billing privileges to Beno Nersissian MD Inc. CMS Ex. 2. Noridian requested additional information to process the

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individual application. By letter dated March 16, 2021, Noridian advised Petitioner that the application had an incorrect PTAN listed for the group and an incorrect signer for the Authorized Official. CMS Ex. 3. Noridian issued a letter of rejection on April 16, 2021, after it received no response to the March 16, 2021 letter. CMS Ex. 4.

A new application was submitted electronically on June 15, 2021, seeking to reassign Dr. Avoian’s Medicare billing privileges to Beno Nersissian MD Inc. CMS Ex. 5. Noridian notified Petitioner on June 22, 2021 that it had approved its June 15, 2021 enrollment application with a “reassignment effective date” of March 17, 2021. CMS Ex. 6 at 1. Petitioner sought reconsideration of the effective date determination, asking that its enrollment and reassignment be effective from January 12, 2021, because Dr. Avoian began seeing patients in January 2021 to cover for Dr. Nersissian’s2 illness. CMS Ex. 7 at 4. In a reconsidered determination dated October 4, 2021, Noridian affirmed its effective date determination of June 15, 2021, and its determination that Petitioner qualified to receive 90 days of retrospective billing because the COVID-19 pandemic constituted a Presidentially declared disaster. CMS Ex. 8.

Petitioner timely filed a request for hearing with the Civil Remedies Division (CRD), and Administrative Law Judge Bill Thomas was designated to hear and decide this case. On December 9, 2021, at Judge Thomas’s direction, the CRD issued an Acknowledgment Letter and Judge Thomas’s Standing Prehearing Order (Pre-Hearing Order) requiring the parties to file arguments and supporting documents in a pre-hearing exchange. Pre-Hearing Order ¶ 5. CMS timely filed its Pre-Hearing Brief and Motion for Summary Judgment (CMS Br.) with 10 proposed exhibits (CMS Exs. 1-10). Petitioner filed its Opposition to CMS’s Motion for Summary Judgment on January 21, 2022 (P. Br.). This case was transferred to me on September 17, 2024.

Petitioner did not object to CMS’s proposed exhibits. As a result, I admit CMS Exhibits 1 through 10 into evidence.

II. Decision on the Record

Neither party offered written direct testimony of a witness as part of its pre‑hearing exchange, meaning an in-person hearing is not necessary in this matter. Pre‑Hearing Order ¶¶ 11-13; Civ. Remedies Div. P. §§ 16(b), 19(b). I therefore decide this case on the record based on the parties’ written submissions and arguments. Civ. Remedies Div. P. § 19(d). CMS’s motion for summary judgment is denied as moot.

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III. Issue

Whether Noridian, acting on behalf of CMS, properly established June 15, 2021, as Petitioner’s effective date for reassignment of its Medicare billing privileges.

IV. Jurisdiction

I have jurisdiction to decide this case. 42 C.F.R. §§ 498.3(b)(15), 498.5(l)(2); see also Social Security Act (Act) § 1866(j)(8) (codified at 42 U.S.C. § 1395cc(j)(8)).

V. Findings of Fact, Conclusions of Law, and Analysis

A. Applicable Law

Petitioner participates in the Medicare program as a “supplier” of services. Act § 1861(d); 42 C.F.R. § 498.2. To receive Medicare payments for services furnished to program beneficiaries, a prospective supplier must enroll in the program. 42 C.F.R. § 424.505. “Enrollment” is the process by which CMS and its contractors: (1) identify the prospective supplier; (2) validate the supplier’s eligibility to provide items or services to Medicare beneficiaries; (3) identify and confirm a supplier’s owners and practice location; and (4) grant the supplier Medicare billing privileges. 42 C.F.R. § 424.502. After a prospective supplier submits an approved Medicare enrollment application, CMS establishes an effective date for billing privileges and may permit retrospective billing pursuant to 42 C.F.R. § 424.521(a).

The effective date for billing privileges for suppliers like Petitioner is “the later of the date of filing” a subsequently approved enrollment application or “the date that the supplier first began furnishing services at a new practice location.” 42 C.F.R. § 424.520(d) (emphasis added). The “date of filing” is the date that the Medicare contractor “receives” a signed enrollment application that the Medicare contractor processes to approval. 73 Fed. Reg. 69,726, 69,769 (Nov. 19, 2008); Donald Dolce, M.D., DAB No. 2685 at 8 (2016).

A Medicare beneficiary may assign the right to receive Medicare Part B benefits for covered medical services to an enrolled supplier who delivers those services. Act § 1842(b)(3)(B)(ii) (42 U.S.C. § 1395u(b)(3)(B)(ii)); 42 C.F.R. § 424.55. In certain circumstances, a supplier who has received an assignment of benefits may reassign those benefits to an employer, or to an individual or entity with which the supplier has a contractual arrangement. Act § 1842(b)(6) (42 U.S.C. § 1395u(b)(6)); 42 C.F.R. § 424.80(b)(1)‑(2). To reassign Medicare benefits, a supplier must submit and obtain CMS’s approval of a reassignment application. Gaurav Lakhanpal, MD, DAB No. 2951 at 1-2 (2019) (citing 71 Fed. Reg. 20,754, 20,756 (Apr. 21, 2006)). CMS applies the effective date rules at 42 C.F.R. §§ 424.520(d) and 424.521(a)(1) to reassignments of

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Medicare benefits. See Medicare Program Integrity Manual (MPIM) (CMS Pub. 100-08) §§ 15.5.20(E)(3), 15.17.

B. Analysis

1. The effective date of Petitioner’s reassignment of Medicare billing privileges is June 15, 20213, as that is the date Noridian received the application it subsequently processed to approval.

Petitioner submitted a reassignment application received by Noridian on June 15, 2021, that the contractor ultimately processed to approval. CMS Ex. 5. The record before me reflects no receipt of an earlier application that Noridian subsequently approved. June 15, 2021, is therefore the correct effective date of reassignment for Petitioner’s billing privileges. Urology Grp. of NJ, LLC, DAB No. 2860 at 7-9 (2018); Willie Goffney, Jr., M.D., DAB No. 2763 at 7 (2017); MPIM §§ 15.5.20(E)(3), 15.17.

Consistent with 42 C.F.R. § 424.521(a)(1)(ii), Noridian also granted Petitioner retrospective billing beginning March 17, 2021, or 90 days before the effective date of reassignment. CMS Ex. 6 at 1; 42 C.F.R. § 424.521(a)(1)(ii).4

2. I have no authority to review Noridian’s decision to reject Petitioner’s prior reassignment application or to otherwise consider Petitioner’s equitable arguments.

Petitioner does not claim to have filed a reassignment application before June 15, 2021, that was approved by Noridian. It instead explains that it filed a reassignment application on March 4, 2021 that was ultimately rejected based on Petitioner’s failure to respond to Noridian’s March 16, 2021 request for information. Petitioner explains that the reassignment was necessary because Dr. Nersissian fell ill and was unable to return to work. Hearing Request at 1-2; P. Br. at 4-5. As a result, Dr. Avoian was brought in to make sure that Dr. Nersissian’s patients were provided needed medical care. Hearing

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Request at 1-2. Petitioner also argues that any correspondence sent to Dr. Nersissian regarding the rejected application was insufficient as he was hospitalized at the time and unable to respond prior to his untimely death. Id.

I am unable to review Noridian’s decision to reject Petitioner’s March 4, 2021 application because the rejection is not an initial determination and “[e]nrollment applications that are rejected are not afforded appeal rights.” 42 C.F.R. § 498.3(b); 42 C.F.R. § 424.525(d). Petitioner may not “seek review of an unappealable rejection of an incomplete application by the ‘back door’ route of challenging the effective date of a later application which was processed to approval.” Wishon Radiological Med. Grp., Inc., DAB No. 2941 at 8 (2019).

Petitioner’s explanation is altogether sympathetic. However, I have no authority to grant Petitioner equitable relief in the form of an earlier effective date of enrollment. US Ultrasound, DAB No. 2302 at 8 (2010). Petitioner points to no authority by which I may grant it relief from the applicable regulatory requirements, and I have no authority to declare statues or regulations invalid. 1866ICPayday.com, L.L.C., DAB No. 2289 at 14 (2009).

VI. Conclusion

For the foregoing reasons, I affirm CMS’s determination of the effective date of Petitioner’s reassignment of Medicare billing privileges to be June 15, 2021, with retrospective billing permitted from March 17, 2021.